Safety and Risk Assessment of No-Prescription Online Semaglutide Purchases

This qualitative study assesses the quality, amount of active ingredient, and characteristics associated with counterfeiting of semaglutide purchased from illegal online pharmacies without a prescription.


Online seller legitimacy classification
Websites were reviewed manually by two authors (ARA and AF) to confirm selling of injectable semaglutide containing products without a prescription and assessed for legitimacy using LegitScript and the National Association of Boards of Pharmacy (NABP) databases, discrepancies were resolved through discussion to reach consensus.All domains were categorized as illegal pharmacies if classified as "rogue" by LegitScript and/or categorized as "not recommended" according to the NABP Safe Pharmacy verification database.LegitScript is a private company that monitors and classifies online pharmacies based on their compliance with applicable laws and regulations.Pharmacies are classified as "rogue" if they are operating out of compliance, illegally or fraudulently.NABP is a nonprofit organization that supports and works with the U.S. state boards of pharmacy and maintains a list of websites that are reviewed for possible fraudulent and unsafe prescription medication sales online.Unverified pharmacy websites, whose domains were not listed in these databases, underwent a thorough manual evaluation to determine legitimacy by two authors independently.

Website content analysis and inclusion criteria for test purchases
Websites inaccessible at time of evaluation, referral sites not offering products directly to customers, duplicate content websites (different domains with identical content), ones requiring valid medical prescription before purchase were excluded, vendors delivering products to Hungary or US, and sites selling products for up to 200 USD per item were included in detailed content analysis.Six were selected 1 for test purchases, two 0.25 mg ampules/doses 1 Links to digital archives of the selected illicit online pharmacies analyzed in this study, hosted on the Internet Archive Wayback Machine.Links are listed in the same order as they appear in the manuscript Table 1.https://web.archive.org/web/20230529141701/https://semaspace.com/ or an equivalent product was ordered from each vendor to simulate the initial 2-week therapy regimen of a patient.Credit cards, PayPal, or bank transfers were the preferred payment options.The chemical and microbiological analyses were to be conducted in Hungary.Therefore, it was deemed preferable for shipments to be directly dispatched to Hungary.In instances where direct delivery to Hungary was not offered by the vendor, the parcels were initially sent to California, USA, and subsequently forwarded to Hungary.

Packaging risk assessment
International Pharmaceutical Federation's (FIP) checklist for visual inspection of medicines, which was initially designed to aid healthcare workers in identification of substandard and falsified products, was adapted for the evaluation of packaging and labelling of delivered products.The checklist evaluates 22 criteria related to packaging integrity, labeling, and regulatory compliance, with each criterion scored as present (1) or absent (0) for a total score range of 0-22.Lower scores indicate higher risk of substandard and falsified medicines.The visual inspection involved observation and photo documentation of the primary and secondary packaging, leaflets and labelling.Scoring discrepancies were resolved through discussion to reach consensus.

Sterility and microbiological contamination
Sterility and microbiological contamination assessment tests were performed on lyophilized peptide samples obtained from Semaspace, Biotech Peptides, and US Chem Labs to assess the product quality.Testing was performed at the ISO 14644-1 certified microbiology laboratory of PharmaValid Ltd. in Budapest, Hungary.Sterility testing was done using direct injection technique according to European Pharmacopoeia (Ph.Eur.11.0 2023 2.6.1) and United States Pharmacopeia (USP-NF2023 ISSUE 2 <71>) guidelines, and bacterial endotoxin content measurement was performed via kinetic turbidimetry technique according to the European Pharmacopoeia (Ph.Eur.11.0 2023 2.6.14) and United States Pharmacopeia (USP-NF 2023 ISSUE 2 <85>) guidelines.

Quantification of active ingredient using liquid chromatography/mass spectrometry
Stock solutions of the standard and the polypeptide samples were prepared in methanol.The working solutions were diluted using water/acetonitrile/formic acid (49/49/2, v/v/v).Chromatographic separation was performed using a Thermo Ultimate 3000 UHPLC™ system (Thermo Fisher Scientific, Waltham, MA, USA) with a Luna Omega PS-C18 reversed-phase column (1.6 μm, 2.1 mm × 150 mm i.d.) from Phenomenex (Torrance, CA, USA).Datadependent mass spectrometric acquisition was performed with a Bruker Maxis 4G UHR-QTOF instrument (Bruker Daltonics, Bremen, Germany).The mass spectrometer was operated in positive ion mode, and the scanning range was set to 300-2200 m/z.